Many rheumatic diseases affect women of childbearing age. In the age of biologic therapy, women are achieving better disease activity and there are increasing numbers of women with rheumatic diseases attempting pregnancy.
Largely because it can be difficult to do studies in pregnant women, gaps remain in the area of rheumatic disease in pregnancy. This year’s ACR highlights some important new points to consider.
The PATCH (Preventative Approach to Congenital Heart Block) study evaluated whether hydroxychloroquine reduced the congenital heart block (CHB) recurrence rate, which has historically been 18%. The study included women initiated or maintained on hydroxychloroquine 400mg by 10 weeks gestation. A total of 65 mothers who had previous CHB were included. 54 mothers were used for analysis and 4/54 (7.4%) developed CHB. This prospective single arm study supports hydroxychloroquine as reducing the recurrence of CHB below the history rate of 18%.
Registries provide valuable information about rare diseases in pregnancy. The Vasculitis Pregnancy Registry (V-PREG) (Abstract 2281) provides some information from the first three years since its inception. The V-PREG is a patient driven research network where pregnant women with any form of vasculitis fill out a survey at entry, during each trimester, and postpartum. V-PREG was able to enrol 62 pregnant women with one of several vasculitidies. The women reported an unusually high rate of prior miscarriage (>40%). Two times that of the general population (typically thought to be 1/5-1/4). Results could be related to disease activity, treatments, or reporting bias. A great place to start nonetheless. Encourage your patients to enroll.
Anti-TNFs are generally considered safe in pregnancy and breastfeeding. Golimumab however previously had the least data in its class. EULAR states that though current evidence does not indicate an increase rate of congenital malformation; because there is limited evidence, alternative medications should be considered. New data from 208 pregnancies, with 211 reported birth outcomes, suggests that the rates of congenital malformations and spontaneous abortions were consistent with published background rate for the general population (Abstract 2288). Though there were limitations, it does provide some extra reassurance if continuing golimumab throughout pregnancy. When a woman is doing well on an anti-TNF prior to conception, it is considered unfavourable to change anti-TNFs. Likewise, Haase et al. (Abstract 2279) reiterates the thought that women with rheumatoid arthritis, who discontinue their anti-TNFi during pregnancy, have higher rates of flares during pregnancy and postpartum.
Additionally, some women require non-TNFi biologics and tofacitinib to control their disease. Evelyn Vinet looks at the infection rates in offspring exposed in utero to non-TNFi biologics and tofacitinib (Abstract 1901). Her group from McGill presents the largest cohort of inflammatory disease offspring ever assembled. Though it appears there were few serious infections in children exposed to non-TNFi biologics or tofacitinib, more studies are necessary.
Though the ACR recommends that patients considering family planning discuss their individual risk with their rheumatologist, it’s evident that counseling doesn’t occur during all visits with our patients (Abstract 2282). A rheumatology clinic in Pittsburgh (Abstract 2277) conducted semi-structured interviews with their patients and identified that their patients wanted their rheumatologist to initiate conversations about family planning repeatedly over time. The women also wanted clear and complete information about their disease and DMARDs, and some were reluctant to continue DMARDs even if compatible with pregnancy.
As more emerging data allows us to better care for our pregnant patients, it’s clear counseling and preparation remain the cornerstone. Counseling and education tools available include rheuminfo.com (search pregnancy) and lupuspregnancy.org.